Authorization for the Administration of Acetaminophen/Ibuprofen - Grades 6-8 Only

Please submit the following form for students in Grades 6-8 only. Thank you.

For students in Grade 6-8 - I authorize the school nurse with a standing order from the school medical advisor to administer acetaminophen (Tylenol) medication at his/her discretion to my child(ren)

Student #1 Name

First & Last Name

Student #2 Name

For FEMALE students in Grade 6-8 - I authorize the school nurse with a standing order from the school medical advisor to administer ibuprofen, up to four (4) doses per month, for dysmenorrhea (menstrual cramps) at his/her discretion to my child(ren)

Student #1 Name

First & Last Name

Student #2 Name

Parent/ Guardian Name

Date

Your Email

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